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CHRONIC DIARRHEA and CELIAC SPRUE Small Group Cases Discussions UMD Medical School February, 2009 Kirk Bernadino, MD.

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Presentation on theme: "CHRONIC DIARRHEA and CELIAC SPRUE Small Group Cases Discussions UMD Medical School February, 2009 Kirk Bernadino, MD."— Presentation transcript:

1 CHRONIC DIARRHEA and CELIAC SPRUE Small Group Cases Discussions UMD Medical School February, 2009 Kirk Bernadino, MD

2

3 Chronic diarrhea –> 4wks duration –Loose/ unformed stool –Usually increased frequency –> 200 grams/24 hrs

4 Chronic diarrhea Gross appearanceGross appearance –Bloody: diarrhea with blood –Fatty (steatorrhea) –Watery: fluid w/o blood or pus

5 Bloody diarrhea –Inflammatory or infectious colitis –Endoscopic mucosal changes EdemaEdema UlcersUlcers FriablilityFriablility

6 Bloody diarrhea Crohn’s colitis Ulcerative colitis

7 Bloody diarrhea –Infectious (INVASIVE) E.coli O157:H7E.coli O157:H7 CampylobactorCampylobactor Salmonella (see photo)Salmonella (see photo) ShigellaShigella YersiniaYersinia Rarely parasitesRarely parasites

8 Chronic diarrhea: bloody Radiation colitis Ischemic colitis

9 Bloody diarrhea Colon polyp Colon cancer

10 Steatorrhea > 5-7 grams fat/24 hrs in stool> 5-7 grams fat/24 hrs in stool SteatorrheaSteatorrhea –Fatty –Oily –Greasy –Light colored –Hard to flush Leaves streaks in toilet bowlLeaves streaks in toilet bowl

11 Steatorrhea Small bowel mucosal processSmall bowel mucosal process Celiac sprueCeliac sprue –Upper GI endoscopy with SB biopsy Whipple’s diseaseWhipple’s disease Tropical sprue--B12/folate deficiency.Tropical sprue--B12/folate deficiency. Small bowel infectionSmall bowel infection –Cryptosporidia, Giardia, Cyclospora Small bowel luminal processSmall bowel luminal process Pancreatic insufficiencyPancreatic insufficiency –Trial pancreatic enzymes

12 Watery diarrhea No bloodNo blood No fatNo fat No pusNo pus Osmotic vs. secretoryOsmotic vs. secretory

13 Watery diarrhea OsmoticOsmotic SorbitolSorbitol FructoseFructose LactoseLactose MannitolMannitol

14 Secretory diarrhea Medication – Mg, NSAIDs, SSRI’sMedication – Mg, NSAIDs, SSRI’s Inflammatory - Crohn’s, Microscopic colitis,Inflammatory - Crohn’s, Microscopic colitis, Chronic infectionsChronic infections IBS/dysmotility - Increased intestinal transientIBS/dysmotility - Increased intestinal transient Diabetic diarrheaDiabetic diarrhea Post-cholecystectomyPost-cholecystectomy Bacterial overgrowthBacterial overgrowth SprueSprue

15 Secretory diarrhea Rare hormomal causesRare hormomal causes –Glucagonoma –Increased serum glucagon level Medullary thyroid cancerMedullary thyroid cancer –Increased serum calcitonin CarcinoidCarcinoid –Increased urinary 5-HIAA VIPomaVIPoma –Increased vasoactive intestinal peptide Zollinger-Ellison syndromeZollinger-Ellison syndrome –Increased gastrin

16 Celiac sprue: Gluten enteropathy Gluten sensitivity Wheat, barley and rye

17 Celiac sprue: Gluten enteropathy IncidenceIncidence –1:250 –Increased in whites/Celtic –Rare in Asians –1:22 incidence in first degree relative

18 Celiac sprue Nonspecific symptomsNonspecific symptoms Diarrhea/steatorrheaDiarrhea/steatorrhea Weight lossWeight loss Abdominal painAbdominal pain Failure to thriveFailure to thrive Short statureShort stature Amenorrhea / infertilityAmenorrhea / infertility Negative impact on pregnancy outcomeNegative impact on pregnancy outcome

19 Celiac sprue Systemic complaintsSystemic complaints –Weight loss –Fatigue / Malaise –Teeth and bone disease –Depression –Dermatatitis herpatiformis –Growth disturbances –Migraines –Easy bleeding Dermatitis herpetiformis

20 Celiac sprue Laboratory findingsLaboratory findings –Anemia –Microcytosis –Iron deficiency –Calcium and zinc deficiency –Fat-soluble vitamin deficiencies (ADEK) –Increased AST, ALT –Elevated fecal fat

21 Celiac sprue: diagnosis Serologic testsSerologic tests Upper small bowel endoscopic biopsyUpper small bowel endoscopic biopsy

22 Celiac sprue: diagnosis Serologic testsSerologic tests –Anti-gliadin antibodies Gluten metaboliteGluten metabolite –Anti-endomysial antibodies Endomysium - smooth muscle proteinEndomysium - smooth muscle protein

23 Celiac sprue: diagnosis tTG (tissue transglutaminase)tTG (tissue transglutaminase) IgA antibody test against the tTG proteinIgA antibody test against the tTG protein IgA deficient patients - false negativeIgA deficient patients - false negative »5-10% of population Gluten free diet lowers titerGluten free diet lowers titer

24 Celiac sprue: pathogenesis Gluten ingestionGluten ingestion Gluten digested to gliadinGluten digested to gliadin tTG binds gliadintTG binds gliadin Antibody to tTG/ligand activates inflammatory responseAntibody to tTG/ligand activates inflammatory response Mucosal edema causes villous atrophy and malabsorptionMucosal edema causes villous atrophy and malabsorption

25 Endoscopy Normal Sprue

26 Celiac Sprue: diagnosis Small bowel biopsy - gold standardSmall bowel biopsy - gold standard –Villous blunting and lamina propria inflammation –tTG and biopsies on gluten free diet

27 Celiac sprue: histology Normal Abnormal Celiac sprue: histology Normal Abnormal

28 Celiac sprue TreatmentTreatment –Gluten free diet –Referral to dietary, allergy, support groups Refractory sprueRefractory sprue Alternative diagnosisAlternative diagnosis LymphomaLymphoma Dietary indiscretionDietary indiscretion –steroids

29 GI clinical Consultation case: celiac sprue 29 yo white female29 yo white female Unable to get pregnant for over two yearsUnable to get pregnant for over two years FatigueFatigue Loose stoolsLoose stools Question: What are her problems and what are some initial hypothesis

30 GI clinical Consultation case: celiac sprue Question: What are her problems and what are some initial hypothesis 1.Infertility 2.Fatigue 3.Intermittent loose stools Hypothesis: 1.Endocrine: hypothyroid 2.Psychiatric: depression/anxiety 3.GI: colitis, sprue, infection 4.Anemia 5.Nutritional deficiencies 6.others

31 GI clinical Consultation case: celiac sprue Question: What further history would you likeQuestion: What further history would you like P alliative: Imodium P rovocative: worse with menses and stress Q uality:watery stools R egion/Radiation: no pain S everity: no blood, ?wt loss, bruising, dry skin T iming: intermittent

32 GI clinical Consultation: celiac sprue Question: What further history would you like PMH: appy Meds: none SH: chef, 3-5 glasses wine/week, no tobacco FH: father is healthy, mother with IBS and hypothyroid, born in Glascow

33 GI clinical Consultation: celiac sprue Question: What further history would you like Physical exam: Thin BMI 18 VSS Afeb Dry skin Abd: unremarkable Trace ankle edema

34 GI clinical Consultation: celiac sprue LabValueNormal Hgb Wbc Plts167k k Mcv Peripheral smear: microcytic anemia Iron Ferritin Tibc Electrolytes, B12 and folate: normal Electrolytes AST ALT Albumin INR1.2<1.2 Vit D68-80 Zinc low

35 GI clinical Consultation: celiac sprue What do you think and what should you do now?

36 GI clinical Consultation: celiac sprue tTG125 (positive > 30)tTG125 (positive > 30) Serum IgA 289 (normal mg/dl)Serum IgA 289 (normal mg/dl) –5- 10 % of population deficient Upper GI endoscopyUpper GI endoscopy –Small bowel biopsy with villious blunting What is diagnosis and now what?What is diagnosis and now what?


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